Bilateral chylothorax complicating massive osteolysis (Gorham's syndrome)

99mTc-SC lymphoscintigraphy and SPECT/CT findings in a case report of Gorham-Stout disease presenting with chylothorax and bone pain

RATIONALE

Gorham-Stout disease (GSD) is a rare disorder characterized by multiple osteolytic lesions, sometimes complicated by chylothorax. The aim of this case report is to introduce a very rare case of Gorham-Stout syndrome, which involved several bones along with chylous pericardial and pleural effusions detected by Tc-sulfur colloid (SC) lymphoscintigraphy and single photon emission computed tomography/computed tomography (SPECT/CT).

PATIENT CONCERNS

A 15-year-old girl presented to our hospital complaining of shortness of breath and bone pain.

DIAGNOSIS

The CT showed multiple osteolytic lesions, left-sided pleural effusion, and pericardial effusion. Tc-SC lymphoscintigraphy showed discontinuation of thoracic duct and tracer accumulation on the left side chest. SPECT/CT revealed increased radioactivity uptake in pleural, pericardial effusions, and some thoracolumbar spines. Diagnostic thoracentesis to identify the nature of pleural effusion and histopathology of biopsy in the right femoral to that of the bone lesion were performed. Based on the clinical information, histopathologic, and radiographic findings, the diagnosis of GSD was made.

INTERVENTIONS

The patient received thoracic duct ligation and bisphosphonates treatment.

OUTCOMES

After receiving thoracic duct ligation and bisphosphonates treatment, the patient's symptoms of bone pain and dyspnea were relieved, and the pericardial and pleural fluid was diminished dramatically. At the 3-month and 9-month follow-up visit, the patient had nearly complete remission without any complication.

LESSONS

The Tc-SC lymphoscintigraphy and SPECT/CT could provide significant value assessing the lymphatic abnormity and evaluating the extent of disease, therefore aiding to guide decision making in the clinic.

Left Functional Pneumonectomy Caused by a Very Rare Giant Intrathoracic Cystic Lesion in a Patient with Gorham-Stout Syndrome: Case Report and Review of the Literature

Gorham-Stout syndrome is an uncommon entity, with few cases reported in bibliography. It consists of osteolytic manifestations affecting various bones and replacing them with lymphangiomatous tissue. With pathophysiology unknown, Gorham-Stout disease affects also cardiorespiratory system usually causing lytic lesions to the bones of the thoracic cage or directly invading the thoracic duct. This is a case report of a unique respiratory manifestation of the disease and a review of its cardiorespiratory complications.

18F-NaF and 18F-FDG PET/CT in Gorham-Stout Disease

Gorham-Stout disease (GSD) is an extremely rare skeletal disorder of unknown etiology characterized by benign proliferation of vascular or lymphatic channels, leading to progressive bone resorption. We report on a patient diagnosed with GSD affecting the right scapula and the right ribs, who underwent PET/CT scans using F-FDG and F-NaF. The remnant upper portion of the affected scapula did not show F-FDG uptake but demonstrated markedly increased F-NaF activity. Furthermore, intense F-NaF activity was seen on the right posterior ribs, which were actively being resorbed, suggesting the potential application of F-NaF-PET/CT imaging in GSD diagnosis and follow-up.

Pregnancy Complicated by Gorham-Stout Disease and Refractory Chylothorax

Introduction Gorham-Stout Disease (GSD) is a rare disorder of bony destruction due to lymphangiomatosis, and is often triggered by hormones. One complication of GSD is the development of chylothorax, which carries a high mortality rate. Very little experience has been published to guide management in GSD during pregnancy to optimize both fetal and maternal health. Case Study A 20-year-old woman with known GSD presented with shortness of breath at 18 weeks of pregnancy, due to bilateral chylothoraces which required daily drainage. To minimize chylous fluid formation, she was placed on bowel rest with total parenteral nutrition (limiting lipid intake) and received octreotide to decrease splanchnic blood flow and chylous fluid drainage. Treatment options were limited due to her pregnancy. Twice daily home chest tube drainage of a single lung cavity, total parenteral nutrition, octreotide, and albumin infusions allowed successful delivery of a healthy 37 weeks' gestation infant by cesarean delivery. Discussion This case illustrates the management of a rare clinical disease of bone resorption and lymphangiomatosis complicated by bilateral, refractory chylothoraces, triggered by pregnancy, in whom treatment options are limited, and the need for a multidisciplinary health care team to ensure successful maternal and fetal outcomes.

Pleural Effusion in Spinal Deformity Correction Surgery- A Report of 28 Cases in a Single Center

OBJECTIVES

To analyze the occurrence, risk factors, treatment and prognosis of postoperative pleural effusion after spinal deformity correction surgery.

METHODS

The clinical and imaging data of 3325 patients undergoing spinal deformity correction were collected from the database of our hospital. We analyzed the therapeutic process of the 28 patients who had postoperative pleural effusion, and we identified the potential risk factors using logistic regression.

RESULTS

Among the 28 patients with postoperative pleural effusion, 24 (85.7%) suffered from hemothorax, 2 (7.1%) from chylothorax, and 2 (7.1%) from subarachnoid-pleural fistula. The pleural effusion occurred on the convex side in 19 patients (67.9%), on the concave side in 4 patients (14.3%), and on both sides in 4 patients (14.3%). One patient with left hemothorax was diagnosed with kyphosis. The treatment included conservative clinical observation for 5 patients and chest tube drainage for 23 patients. One patient also underwent thoracic duct ligation and pleurodesis. All of these treatments were successful. Logistic regression analysis showed that adult patients(≥18 years old), congenital scoliosis, osteotomy and thoracoplasty were risk factors for postoperative pleural effusion in spinal deformity correction surgery.

CONCLUSIONS

The incidence of postoperative pleural effusion in spinal deformity correction surgery was approximately 0.84% (28/3325), and hemothorax was the most common type. Chest tube drainage treatment was usually successful, and the prognosis was good. Adult patients(≥18 years old), congenital scoliosis, and had undergone osteotomy or surgery with thoracoplasty were more likely to suffer from postoperative pleural effusion.

GORHAM-STOUT SYNDROME: PHANTOM BONE DISEASE

Gorham-Stout syndrome is a disease that presents idiopathic osteolysis of a bone or closely contiguous area. The etiology is unknown. It is a rare condition that is difficult to diagnose, and its treatment is controversial. It affects individuals irrespective of age or sex. In this study, we conducted a bibliographic review of the disease, specifically focusing on the differential diagnosis, and we demonstrated the follow-up on a patient with this syndrome from the time of its diagnosis, through treatment, to its current state of evolution.

Viewpoints on vessels and vanishing bones in Gorham-Stout disease

Gorham-Stout disease (GSD) is a rare disorder characterized by the proliferation of endothelial-lined vessels in bone and the progressive destruction of bone. Although Jackson described the first case of GSD in 1838, the clinical and histological features of GSD were not defined until Gorham and Stout published their report on massive osteolysis in 1955. In the years since Gorham and Stout's groundbreaking publication, more than 300 cases of GSD have been described in the literature. These reports have revealed that the progressive resorption of bone in GSD causes severe physical deformities, disabilities, and life-threatening complications. Unfortunately, the underlying cause of GSD remains unknown and, as a result, the therapeutic options for individuals with GSD are limited. Here we review the latest advances in GSD research and present strategies to address basic and clinical research questions related to GSD.

Gorham's Disease complicated with bilateral chylothorax and successfully treated with Interferon-alpha-2a

Gorham's disease (GD) is rare and characterized by non-neoplastic lymphovascular proliferation and massive osteolysis. Its clinical course is usually protracted, but sometimes life threatening when vital structures are involved or when complicated with chylothorax. There is no optimal treatment guideline for GD complicated with chylothorax. Surgical ligation of thoracic duct, pleurectomy, pleurodesis, interferon-alpha-2b, and radiotherapy, are reported to manage chylothorax. We present the case of a 32-year-old man with Gorham's disease complicated by bilateral chylothorax, which was refractory to radiotherapy but remitted dramatically two weeks after interferon-alpha-2a therapy. The patient was free of relapse four months after discontinuing four-month interferon therapy. To date, only 11 cases (including ours) of GD with chylothorax have received interferon as single or salvage therapy, and 10 of them survived. Early intervention with interferon therapy can be considered as an effective treatment for GD complicated with bilateral chylothorax.

Gorham-Stout syndrome with chylothorax in a six-year-old boy

Gorham-Stout syndrome, also called "disappearing bone disease, diffuse cystic angiomatosis of bone, disseminated lymphangiomatosis, Gorham's vanishing bone disease, phantom bone disease or idiopathic massive osteolysis, is a rare disease of unknown etiology and pathogenesis. It is characterized by rapidly progressive localized massive osteolysis associated with proliferation of vascular structures of benign origin in which the absence of new bone formation is representative. When it is complicated by chylothorax, the prognosis is poor. The authors report a 6-year-old boy with Gorham-Stout syndrome who presented with pleural effusion showing features of chylothorax, who responsed poorly to currently available therapeutic modalities.

A rare cause of dyspnea due to chylothorax

We report the case of an 8-year-old boy who presented to the emergency department of another hospital and was referred to our pediatric intensive care unit with dyspnea and tachypnea of recent onset. The diagnosis of massive chylothorax with mediastinal shift was made on chest radiographs and CT scan. Initial investigations revealed no definite cause for the chylothorax. On later radiography and CT imaging with 3D surface rendering, a marked bone loss of the left ribs, clavicle, and shoulder joint was shown. The diagnosis of Gorham-Stout disease associated with chylothorax was suspected and histologically confirmed.

Vanishing bone disease: review and case reports

Vanishing bone disease is a rare idiopathic disease, leading to extensive loss of bony matrix, replaced by proliferating thin-walled vascular channels and fibrous tissue. There are >191 cases reported in the English literature. Gorham and Stout made the first overview of the disease in 1955 and they first presented 24 cases known at that time. The etiology remains speculative, the prognosis unpredictable, and effective therapy still unknown. The disease can be monostotic or polyostotic although multicentric involvement is exceptional. We report 2 cases of a histologically studied vanishing bone disease involving the humerus and the femoral head. The patients' past history was noncontributory. The radiographic study revealed a destructive lesion of the left humerus in the first case, and complete disappearance of the femoral head in the second case. Laboratory findings including hormonological tests revealed no evidence of metabolic, immunologic, neoplastic, or infection etiology. Histopathological findings of the 2 cases revealed thickened bone of lamellar structure without marrow cavities next to fibrous tissue, with few fibroblasts and a small number of newly formed vascular channels. The prognosis varies from slight disability to death by involvement of vital skeletal structures. The treatment of vanishing bone disease is controversial. Several treatment modalities have been proposed. Surgical intervention has been suggested as a method of choice by many authors and concerns local resection of the affected bone, with or without replacement prosthesis or bone grafts.

Gorham's disease complicated by chyloma of the chest wall

Gorham's disease is a rare disorder characterized by a non-malignant proliferation of thin-walled lymphatic vessels that result in progressive bony destruction and often extend into the surrounding soft tissues. Chylothorax is a common complication in cases of mediastinal involvement. Here we report a case of a 22-year-old male with Gorham's syndrome complicated by chyloma of the chest wall, but without chylothorax. To our knowledge, this is the first report demonstrating an abnormality of the parietal pleura prior to the clinical development of the chylothorax.

Gorham-Stout syndrome in a male adolescent-case report and review of the literature

Gorham-Stout syndrome is a rare disease characterized by vascular proliferation in the bones, effecting osteolysis. When it is complicated by chylothorax, the prognosis is poor. The present case illustrates successful management of chylothorax by a combination of surgery (thoracic duct ligation and excision of lymphangiomatous tissue combined with pleurodesis) and treatment with alpha-2b interferon. Treatment in 38 published cases is reviewed.

Gorham's disease or massive osteolysis

Gorham's disease is a rare disorder characterized by proliferation of vascular channels that results in destruction and resorption of osseous matrix. Since the initial description of the disease by Gorham and colleagues (1954) and by Gorham and Stout (1955), fifty years have elapsed but still the precise etiology of Gorham's disease remains poorly understood and largely unknown. There is no evidence of a malignant, neuropathic, or infectious component involved in the causation of this disorder. The mechanism of bone resorption is unclear. The clinical presentation of Gorham's disease is variable and depends on the site of involvement. It often takes many months or years before the offending lesion is correctly diagnosed. A high index of clinical suspicion is needed to arrive at an early, accurate diagnosis. Patients with Gorham's disease may complain of dull aching pain or insidious onset of progressive weakness. In some cases, pathologic fracture often leads to its discovery. Gorham's disease is progressive in most patients; however, in some cases, the disease process is self-limiting. The clinical course is generally protracted but rarely fatal, with eventual stabilization of the affected bone being the most common sequelae. Chylous pericardial and pleural effusions may occur due to mediastinal extension of the disease process from the involved vertebra, scapula, rib or sternum, and can be life threatening. A high morbidity and mortality is seen in patients with spinal and/or visceral involvement. The medical treatment for Gorham's disease includes radiation therapy, anti-osteoclastic medications (bisphosphonates), and alpha-2b interferon. Surgical treatment options include resection of the lesion and reconstruction using bone grafts and/or prostheses. In most cases, bone grafts tend to undergo resorption and are not helpful. Surgical reconstruction and/or radiation therapy are used for management of patients who have large, symptomatic lesions with long-standing, disabling functional instability. Surgical stabilization may be required for unstable spinal lesions. Various treatment options, including pleurectomy, pleurodesis, thoracic duct ligation, radiation therapy, interferon therapy, and bleomycin, have been used for management of patients with Gorham's disease presenting with chylothorax. In general, no single treatment modality has proven effective in arresting the disease.

Chylothorax complicating Gorham's disease

Gorham's disease is a rare disorder characterized by a proliferation of thin-walled lymphatic vessels (lymphangiectasia) resulting in an osteolysis. A chylothorax is present in about one-fifth of the patients and carries a poor prognosis. In this circumstance, surgery including thoracic duct ligation, pleurodesis, and excision of involved tissue is probably the treatment of choice. It is facilitated by a precise radiological assessment using a computed tomographic scanning coupled with a lymphography. We report such a case.

How to recognize and treat specific low back pain?

A wide variety of mechanical and non-mechanical disorders are associated with the clinical symptom of low back pain. Mechanical disorders are the cause of the vast majority of low back pain. Despite this frequency, the specific cause of mechanical low back pain can not be elucidated in spite of extensive diagnostic evaluation in a majority of individuals. Specific causes of low back pain are associated with less frequently occurring systemic illnesses including rheumatic, infectious, neoplastic, gynaecological and vascular disorders. The diagnostic process is more successful in identifying systemic disorders as the specific cause of low back pain. Non-surgical management is effective therapy with most patients with mechanical disorders of any form. Systemic illnesses require interventions directed specifically at healing the affected organ system.